Arrowhead Post Acute LLC

Based on observations, staff interviews, and record review, the facility failed to ensure that one of three residents (R) (R27) reviewed for pressure ulcers out of a total sample of 34 sampled residents was provided with a pressure-relieving device to relieve pressure between bony prominences. This failure had the potential to place R27 at risk for pressure ulcer development. Findings include: Review of R27's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 2/7/2014 with diagnoses including dysphagia following an unspecified cerebrovascular disease, aphasia, hemiplegia, and hemiparesis following cerebral infarction affecting the left dominant side. Review of R27's most recent Annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 8/17/2024, revealed the resident had severely impaired cognitive skills for daily decision making. R27 had limitations in range of motion, had impairment on both sides in the upper and lower extremities, and was dependent on staff for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

2. Review of R8's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility with diagnoses that included seizures, aphasia, and deaf non-speaking. Review of R8's quarterly MDS, with an ARD of 3/13/2025 and located under the MDS tab of the EMR for Section C (Cognitive Patterns) revealed, he scored zero out of 15 on the BIMS, indicating severely impaired cognition; Section D (Mood) revealed, R8 did not exhibit any mood or behavioral symptoms, and Section N (Medications) revealed, he used antianxiety medication. Review of R8's Care Plan, dated 4/27/2025 and located under the Care Plan tab of the EMR, revealed, [R8] uses anti-anxiety medications r/t [related to] anxiety disorder. The approaches included Give anti-anxiety medications ordered by physician. Review of R8's Medication Administration Record (MAR), located under the Orders tab of the EMR and dated May 202025, revealed a physician's order, which originated on 4/17/2025, for lorazepam (an antianxiety medication), 0.5 milligrams (mg) three times daily for anxiety. Further review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of the facility's policies titled Storage of Medications F 761 and 5.3 Storage and Expiration Dating of Medications and Biologicals, the facility failed to remove expired medications from one of two medication carts located on the Left Wing. This deficient practice had the potential to place the residents at risk of receiving medications with altered effectiveness. Findings include: Review of the facility's policy titled, Storage of Medications F 761, reviewed 3/2025, indicated, . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed per state regulation . Review of the facility's policy titled, 5.3 Storage and Expiration Dating of Medications and Biologicals, reviewed 8/1/2024, indicated, . Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility's policy titled Evaluations, the facility failed to ensure one of one resident (R) (R184) reviewed for rehabilitation out of a sample of 34 residents received timely speech therapy services when ordered to address a swallowing problem. This failure had the potential to place R184 at risk of a decline in swallowing function and dissatisfaction with pureed meals, which could contribute to weight loss or malnutrition. Findings include: Review of the facility's policy titled Evaluations, dated 10/4/2024, revealed, Evaluations will be initiated within a reasonable amount of time following receipt of a physician's order, authorization, or according to facility policy. Review of R184's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses that included dysphagia, anxiety, depression, and failure to thrive. Review of R184's admission Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of the facility policy titled Guidelines for Charting and Documentation, the facility failed to ensure the clinical record accurately reflected the status of one of 34 residents (R) (R8) related to use of a wander guard (departure alert system). This failure created a misrepresentation of care being provided. Findings include: Review of the facility policy titled Guidelines for Charting and Documentation, dated June 2024, revealed, Be concise, accurate, and complete and use objective terms . Document only the facts. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, seizures, absence of right leg above the knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/2025 and located under the MDS tab of the EMR, revealed he scored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility's policy titled Infection Control Program - Antibiotic Stewardship, the facility failed to ensure that antibiotics were not used without the presence of a diagnosed infection for one of three residents (R) (R53) reviewed for antibiotic stewardship out of a total sample of 34 residents. The failure had the potential to lead to increased antibiotic resistance or adverse side effects related to unnecessary antibiotic usage. Findings include: Review of the facility's policy titled Infection Control Program - Antibiotic Stewardship, dated October 2024, revealed, After order has been received, the Infection Control Coordinator or designee should complete the surveillance document, utilizing the McGeer criteria, noting evidence for the infection. If the antibiotic does not fit the criteria, the physician will be contacted. Review of the facility's Infection Control Log, used to track infections and antibiotic usage, revealed R53 was listed with a urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to maintain proper ventilation in six resident rooms and on the main hall of the facility to ensure adequate air circulation and environmental hygiene. This failure had the potential to contribute to residents' discomfort and poor air quality for all 80 residents currently residing in the facility. Findings include: 1. Observations made beginning on 6/9/2025 at 9:09 am on the right wing of the facility identified bathroom ventilation fans were found not operational in rooms 125, 131, 133, and 137. On 6/12/2025 at 12:45 pm, the Maintenance Director Assistant (MDA), the Housekeeping Director (HKD), the Administrator, Director of Nursing (DON), and Corporate staff accompanied the surveyors on a tour of the building and confirmed identified concerns, including rooms where the ventilation fans were not working. The MDA verified that the ventilation fan was not working in room [ROOM NUMBER], with tissue paper, as there was no updraft of the paper. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's policy titled, Vaccination of Residents, Including Influenza, Pneumococcal, Respiratory Syncytial Virus (RSV), and COVID-19, Reporting of, the facility failed to offer or provide documentation of consent or refusal of vaccinations for five of five residents (R) (R7, R14, R53, R66, and R72) reviewed for vaccination consents. Findings include: Review of the facility's policy titled Vaccination of Residents, Including Influenza, Pneumococcal, RSV, and COVID-19, Reporting of last revised September 2023, revealed Guidelines, General Immunization: 3. Evaluate new residents vaccination status upon admission. 4. The resident or resident's legal representative may refuse vaccinations for any reason. 5. Residents have the right to refuse, be free of interference, coercion, discrimination, and reprisal of the community staff for refusing to take any vaccines. 6. If vaccinations are refused, the refusal shall be documented in the resident's medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled, F 625 Bed Hold, the facility failed to ensure a bed-hold policy upon transfer to the hospital for one of 35 sampled residents (R) (R79). Findings include: Review of the facility policy titled F 625 Bed Hold revised May 2023 indicated the following: 1. Upon admission and when a resident is transferred for a non-emergency hospitalization or for therapeutic leave, a representative of the business office will provide information concerning our bed-hold policy. 2. When emergency transfers are necessary, the facility will provide the resident and the resident representative with information concerning our bed-hold policy per state law as applicable. R79 was admitted to the facility with diagnosis including but not limited to encounter for surgical aftercare following surgery on the digestive system, diabetes mellitus, cocaine dependence with intoxication delirium, major depressive disorder, and insomnia. Review of R79's Physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, F 656, F 657, F 658 Comprehensive Care Plan, the facility failed to develop and implement a care plan for activities of daily living (ADL) for one of 35 sampled residents (R) (R8). The deficient practice had the potential for decline in R8's functional abilities. Findings include: Review of the facility's policy titled F 656, F 657, F 658 Comprehensive Care Plan revised August 2022 documented under Policy: An individualized comprehensive resident centered care plan that includes measurables objectives and time frames to meet the residents medical, nursing, mental, cultural and psychological needs is developed for each resident. Procedure: 8. Each resident's comprehensive care plan is designed to: . f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. 1. Review of the electronic medical record (EMR) for R8 revealed diagnoses that included but not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to have an order for oxygen (O2) therapy for one of three residents (R) (R72) on oxygen therapy. The deficient practice had the potential to cause delayed treatment. Findings include: A review of the facility policy titled Oxygen Administration last revised June 2021 revealed under Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Under Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident. Review of the electronic medical record (EMR) for R72 including the Minimum Data Set (MDS) section C-Cognition revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates that cognition is intact. Under section J-Health Conditions revealed R72 has shortness of breath or trouble breathing with exertion, shortness of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure there was a clean, comfortable environment, as evidenced by dirty and stained walls, floors, privacy curtains and air conditioning vents and missing or broken floor tiles in resident rooms/bathrooms and common areas. These environmental concerns were observed in the corridors on two of two wings, in eight resident rooms, and in one day room. Findings include: A review of the policy titled, Cleaning and Disinfection of Environmental Surfaces F880, effective 05/2021, revealed, 9. Housekeeping surfaces (e.g. [for example], floors, tabletops) will be cleaned on a regular basis and when surfaces are visibly soiled. 10. Environmental surfaces will be disinfected on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 11. Walls, blinds and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. During an initial tour of the facility, on 03/21/2022…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to develop and implement comprehensive care plans for four (Residents #9, #22, #72, and #78) of 19 sampled residents whose care plans were reviewed. Findings include: A review of the facility's policy titled, Care Plans - Comprehensive, revised 11/2017, indicated, An individualized comprehensive person care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The facility's care planning interdisciplinary team, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem area; b. Incorporate risk factors associated with identified problems. 1. Resident (R) #9 was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus. Review of the admission Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of the facility policy, the facility failed to maintain the dignity of a resident while in the dining area for one of two residents (Resident [R] #37) reviewed for dignity by not cutting their food or assisting during a meal and allowing the resident to eat with their fingers. Findings include: A review of the facility's policy, Respect and Dignity, reviewed on 05/2021, indicated under policy statement that residents have the right to be treated with respect and dignity. The policy also indicated, Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility admitted R #37 on 08/31/2012 with diagnoses that included cognitive communication deficit, need for assistance with personal care, generalized muscle weakness, dysphagia, cataracts, diabetes, depression, and a stroke affecting the dominant side. A review of the annual Minimum Data Set (MDS), dated [DATE], indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, document review, and review of policy and procedures, the facility failed to ensure a resident's right for a homelike environment that meets the resident's needs, including a wheelchair, and access to a bathroom for two of nineteen residents (Resident #18 and Resident #39) reviewed for resident rights. Findings include: A review of the facility's policy titled, Safe, Clean, Comfortable, Homelike Environment F584, revised 11/2017, revealed, Policy Statement: Residents have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely Policy Interpretation and Implementation: 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 1. A review of Resident (R) #18's admission Record indicated the facility admitted R#18 with diagnoses including cerebral palsy, Lennox-Gastaut syndrome, and unspecified intellectual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record reviews, and review of a facility policy, the facility failed to provide showers as planned and desired for one of two residents (Resident [R]#9) who was reviewed for choices for showers. Findings included: A review of the facility's policy titled, Shower/Tub Bath, dated 05/2021, indicated the purpose of the policy was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Under Documentation, the policy indicated the information to be recorded included the date and time the shower/tub bath was performed. The policy instructed staff to notify the supervisor if the resident refuses the shower/tub bath. The facility admitted R#9 on 12/21/2021 with diagnoses that included end stage renal disease, diabetes, protein calorie malnutrition, pressure ulcer and depression. A review of the admission Minimum Data Set (MDS) dated [DATE] , indicated the Brief Interview for Mental Status score was 12 out of 15 which indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, record review, and facility policy review, the facility failed to notify a resident representative of missed dialysis appointments, change in condition and transfer to the hospital for one of two residents (Resident (R) #22) that received hemodialysis services. Findings include: The facility policy titled, Change in a Resident's Condition or Status F580, with an effective date of 05/2021 indicated, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and consistent with the delegation, the resident's representative when there has been: b. a significant change in the resident's physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications, d. A need to transfer the resident to a hospital/treatment center. A review of the Face Sheet indicated the facility readmitted R#22 on 05/03/2021. Admitting diagnoses included but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure a discharge summary was completed for one (Resident [R] #80) of one resident reviewed for discharge requirements. This had the potential to affect 11 residents with planned discharges from the facility. Findings include: A review of the facility's policy titled, Discharge Summary and Plan F660, F661, revised 11/2017, indicated, Policy Statement: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her living environment. 7. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. Review of the admission Record, dated 01/22/2022, revealed R#80 had diagnoses which included type two diabetes mellitus,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to consistently provide nail care and oral care for one of three dependent residents (Resident [R] #22) observed for activities of living. Findings include: The facility's policy titled, Mouth Care with an effective date of 05/2021, indicated the purpose of the policy was to keep the resident's lips and oral tissue moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth. A facility policy for nail care was not provided. A review of R#22's quarterly Minimum Data Set (MDS) dated [DATE] indicated R#22 was readmitted to the facility on [DATE] and had diagnoses which included non-Alzheimer's dementia, end stage renal disease, diabetes, malnutrition, and seizure disorder. The MDS indicated the resident scored 6 on the brief interview for mental status, indicating severe cognitive impairment. The resident was identified on the MDS as totally dependent on staff for personal hygiene and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to document accurate intake of meals and percentage of nutritional supplement consumed for one of two residents (Resident #37) reviewed for nutrition. Findings include: The facility admitted R#37 on 08/31/2012 with diagnoses that included cognitive communication deficit, need for assistance with personal care, generalized muscle weakness, dysphagia, cataracts, diabetes, depression, and stroke affecting the dominant side. A review of the Order Summary Report indicated R#37 had a physician's order dated 04/03/2018 for a carbohydrate-controlled diet with no added salt. The consistency was mechanical soft with ground meat texture. A review of the Weights and Vitals Summary indicated on 12/10/2021, R#37's weight was recorded on the weight record as 107.7 pounds. A review of an RD Note dated 12/16/2021 documented staff reported the resident's average food intake as 58% to 83%. The RD indicated R#37 had sustained significant weight loss and recommended the resident start Med Pass (a liquid high calorie supplement)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to maintain a Registered Nurse (RN) on duty for eight consecutive hours per day, seven days per week. This had the potential to affect all 80 residents. Findings include: A review of the Facility Two Week Staffing Grid dated 03/01/2022 through 03/14/2022 revealed the facility had an RN in the building eight hours per day on four of the 14 days reviewed. An RN was present in the building for eight hours on 03/05/2022, 03/06/2022, 03/12/2022, and 03/13/2022. During an interview with the Medical Records Director (MRD) LL on 03/23/2022 at 3:30 PM, MRD LL stated she was responsible for staffing for the facility. MRD LL reviewed the staffing sheets and confirmed there had been RN coverage for four shifts out of 14 days. She stated there had been no problems with RN staffing until the Assistant Director of Nursing (ADON) quit at the end of February 2022. MRD LL stated both the Director of Nursing (DON) and the Administrator were aware of the lack of RN coverage, since they both received a copy of the staffing from her twice a week.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of policy and procedures, the facility failed to ensure social services, including referrals to other facilities closer to a resident's family, were provided for one of three residents (Resident [R] #19) whose responsible party (RP) had requested a transfer. Findings include: A review of the facility's policy titled, Discharge Summary and Plan F660, F661, revised 11/2017, revealed, Policy Statement: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Policy Interpretation and Implementation. 4. For residents whom [sic] are going to be transferred to another SNF [skilled nursing facility] or whom are discharged to a HHA [home health agency], IRF [inpatient rehabilitation facility] or LTCH [long term care health facility], assist the resident or representative in selecting such locations by utilizing data such as standardized patient assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.